key: cord-0926910-yj53hdba
authors: Santos, Juliana Amorim dos; Normando, Ana Gabriela Costa; Silva, Rainier Luiz Carvalho da; Paula, Renata Monteiro De; Cembranel, Allan Christian; Santos-Silva, Alan Roger; Guerra, Eliete Neves Silva
title: Oral mucosal lesions in a COVID-19 patient: new signs or secondary manifestations?
date: 2020-06-09
journal: Int J Infect Dis
DOI: 10.1016/j.ijid.2020.06.012
sha: 217a5905b81892e7cd74ab7bd2fc22646982e5b9
doc_id: 926910
cord_uid: yj53hdba

Some oral manifestations have been observed in patients with coronavirus disease in 2019 (COVID-19). However, there is still a question about whether these lesions are due to coronavirus infection or secondary manifestations resulting from the patient's systemic condition. Thus, this article aims to report an additional case of the oral conditions in a patient diagnosed with COVID-19. Our patient, a sixty-seven-year-old Caucasian man, tested positive to coronavirus and presented oral manifestations such as recurrent herpes simplex, candidiasis, and geographic tongue. We support the argument that some oral conditions could be secondary to the deterioration of systemic health or due to treatments for COVID-19. The present case report highlights the importance of including dentists in the intensive care unit multi-professional team to improve oral health in critical patients not only COVID-19 patients. Also, to contribute to evidence-based and decision-making in managing infectious diseases.

On March 31 st , 2020, a sixty-seven-year-old Caucasian man with a history of cruising the Brazilian coast in the past 30 days was admitted at Hospital Alvorada Brasília, Brasilia, Brazil. Ten days earlier, the patient developed respiratory symptoms and progressive dyspnea on exertion, in addition to fever and diarrhea. The patient was asked about symptoms of gustatory and olfactory disfunction, and he reported hypogeusia. In the medical history, the patient reported coronary J o u r n a l P r e -p r o o f disease, already revascularized, systemic hypertension, autosomal dominant polycystic kidney disease, and kidney transplant, which led him to take immunosuppressants regularly and to use pharmacological prophylaxis for venous pulmonary thromboembolism with Enoxaparin sodium (Clexane® 20mg/day). A nasopharyngeal swab following reverse-transcription polymerase chain reaction (RT-PCR) for SARS-CoV-2 RNA amplification resulted in positive. Chest computed tomography evidenced bilateral diffuse hyperdense infiltrations in the so-called "ground glass" pattern affecting both lungs, leading to intensive care unit (ICU) admission for supplemental O2.

Thereafter, the patient underwent orotracheal intubation due to disease progression and respiratory failure, and the patient was treated with Hydroxychloroquine sulfate (Reuquinol®, 400mg/day), Ceftriaxone sodium (2g/day), and Azithromycin (Zitromax® 500mg/day) for seven days.

Due to clinical suspicion of pneumonia associated with mechanical ventilation, and worsening of the white blood cell count, a new antibiotic regimen was started with Meropeném (Meronem®, 1000mg, 8/8hs) and Sulfamethoxazole+Trimetropin (Bactrim®, 400mg +80mg, 1.5 ampule, 8/8hs) for 10 days. Then, the patient underwent a tracheostomy. Hemodialysis was performed with subsequent recovery of renal function. The mechanical ventilation was maintained with good recovery and the possibility of spontaneous breathing. Also, the patient returned to the use of immunosuppressants and pharmacological prophylaxis for venous and pulmonary thromboembolism with Enoxaparin sodium (Clexane® 60mg/day).

On the twenty-fourth day of hospitalization, the dentists (R.L.C.S. and R.M.P.) were called to assess a persistent white plaque on the tongue dorsum. This lesion was previously treated by the physicians with intravenous Fluconazole (Zoltec® 200mg/100mL, one bag a day for 10 days) and oral nystatin (100,000 IU/mL, 8/8h, for 30 days), but no regression was observed. In addition to the white plaque, the dentist also observed multiple pinpoint yellowish ulcers in the tongue dorsum J o u r n a l P r e -p r o o f resembling the late stage of herpetic recurrent oral lesions (Fig. 1A) . After a complete intraoral examination, no other lesions on the oral mucosa were observed, except for a nodule located in the lower lip, measuring approximately 1 cm in its largest diameter, suggestive of a reactive lesion (fibroma) that was confirmed by the patient's pre-existence. Tongue scrape culture was performed, which was compatible with Saccharomyces cerevisiae. Extremely viscous saliva was observed, and biopsies were not recommended due to the patient's systemic conditions. And, cutaneous lesions were not observed during the patient's physical examination. At this time, the patient kept the antifungals and was treated with chlorhexidine digluconate (0.12%) alcohol-free mouth rinses, in addition to daily applications of 1% hydrogen peroxide. The dentist also instructed the health team on the importance of maintaining oral hygiene care.

Two weeks after the first oral examination, the white lesions on the tongue dorsum showed almost complete resolution. In a new intraoral examination, it was observed that the patient presented an asymptomatic geographic tongue classified as severe, according to the severity index recently published (Picciani et al., 2019) (Fig. 1B) , associated with fissured tongue.

The patient was discharged from the ICU and in the subsequent days, there was a prompt recovery. The patient had no fever and the physician had been able to gradually decrease oxygen flow, and antibiotic therapies were discontinued. At that moment, in a hospital apartment, he was conscious, oriented, and not dependent on oxygen therapy. Also, the patient had no complaints, preserved appetite, good water consumption, good urine volume, and afebrile.

On May 14th, the patient was discharged after forty-four days of hospitalization, also the dentist only prescribed oral health care. Ten days later, the patient sent us an intraoral image where it could be observed maintenance of geographic tongue but now classified as moderate, according to the severity index recently published (Picciani et al., 2019) . In addition, a slightly erythematous J o u r n a l P r e -p r o o f area could be seen in the right palatine tonsil region, however, the patient reported being asymptomatic (Fig. 1C ). . We also can observe a slightly erythematous area in the right palatine tonsil region, however, the patient reported being asymptomatic.

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